Since I could never pin Randy down to write about his experience thus far, an interview format seemed like a good way to share what he’s doing. Driving up to Kamuzu Central Hospital I asked:

What’s the pediatric patient make-up at KCH?

Randy: Mostly, younger children because they are at higher risk for disease, malaria and malnourishment. Forty percent of the population of Malawi lives on under $2.00/day and 15% live on under $1.25 (extreme poverty). Those under five are the most vulnerable. Some parents have the ability to speak English and may wear nicer clothes, but the majority are impoverished.

What kind of diseases are you seeing?

Randy: Top of the list is malaria, perhaps because it is the season for it. Half to three-quarters of the walk-ins are malaria and most of those are severe. They come in with high fevers, headaches and severe anemia because most are so young and have no antibodies to the disease. Often they are convulsing due to the severity. Treating them is tricky either because there’s not enough blood and they need a transfusion or the disease is so advanced involving the brain that all treatment actions are to no avail. Two to three children die every day due to severe anemia caused by malaria. Second would be respiratory distress due to pneumonia, bronchiolitis or lung injury from AIDS related organisms. Then there’s HIV/tuberculosis/malnutrition–sometimes independent of one another but often some mix of all three. Fourth, a lot of gastrointritis. Then there are the uncommon things that you’d see in any country–kidney and liver injury, cancer, congenital heart diseases. But nearly all in the most advanced stages of their disease, so it is more common to see things that you only read about in textbooks but don’t usually actually encounter.

What are the biggest heath issues for the patients you’re seeing?

Randy: While malaria is the most frequent disease, the biggest health issue long term is HIV. Six percent of the children who walk in have HIV, which not only complicates whatever other disease they may have but its what will kill them. There is tuberculosis, malnourishment and lack of immunizations–a 14 year-old patient died of tetanus Friday–which are all big issues here but where these can be addressed, children will get better and survive. There is no cure for HIV and its what compromises them to fight these other diseases and live.

What’s a typical day for you at KCH?

Randy: I generally get in about 8:00 for the conference with the clinical officers, interns, junior people. My colleague, the only other senior doctor at this time (from Germany) is usually already there checking up on patients. We wait around to start the conference because usually there’s a lot of people missing and no one is ready to report about the patients. Eventually someone starts reporting which patients have died and the numbers in and out. By around 9 it ends and all leave to go take care of things. Between 9-1:30 I try to get a language guide and see patients, checking charts and following up on what’s being done for different ones. It’s frustrating because it’s difficult to get information from the charts and to figure out where the patients are, so I spend a lot of time chasing down patients. Staff are around working but sometime between 11:30-1:30 a lot of them seem to just disappear, maybe for lunch??? maybe for the day?? They are suppose to have coverage, sometimes they do, its just hard to know where they are. At 1:30 the other senior doc and I might go across the street to a little place for some lunch but often we just keep working right up to 4:00 when the “turn over” is to occur. That’s when the day people are to let those staying for the night shift know about the patient–but again it’s just a lot of chaos. From 4-6/7 we are usually in the Treatment Room trying to triage the patients that have come in before leaving for the night. That seems to be the time the volume really picks up as they have taken all day to get to the hospital from the surrounding areas. For the most part it all seems chaos because there’s so many patients, all severe, all with one or two parents with them and the space is very small–two or three to a bed with less than two feet between beds. I am literally ON my feet all day long, there is no place to sit down and not a free minute to do so. The only break might be to walk out of the ward for a brief lunch but even that doesn’t always happen because there’s just so much going on.

What have been the most frustrating factors you’re encountering?

Randy: The most frustrating thing is a system which can’t deliver care to the people who need it because its disorganized. Not just a lack of medicine, resources and personnel but disorganization, a lack of follow through, no effective communication system to report on a patient’s care and their treatment plan. It’s all very chaotic. While prevention could have kept a lot of people out of the hospital, the same number of people could take care of all the patients if it wasn’t so disorganized. That’s not to say there’s not a lot of good effort, even early identification of disease. It’s just that there is no communication exchange and there’s a lack of follow through on what needs to be done to manage the patients. A better system for people to be alert to things, caring for and having resources, stocking things, anticipating and following through would lead to much better care for the same number of patients with the same amount of resources. It’s really frustrating to see the impact of disorganization and what seems to come off as not caring (at least from my own cultural perspective) be the gap in what could have been prevented or treated.

Have you seen some positive outcomes?

Randy: Yes, I’ve seen children with malaria and meningitis get better, going from seizures and high fevers one day to laughing and smiling a few days later. I’ve seen people take their children home after a 3-4 day stay and even some of the sickest after a weeks stay get better and go home. We do have rapid malaria test kits which are great for a quick diagnosis its just that they often run out or “are not available today”. Having the residents from Children’s has been good too. Although they have been quite sobered by the whole experience they have been able to be very “hands on” and can do quite a bit procedurally since language skills are not as necessary, which has been good and helpful.

OK Randy, I’m never going to complain about the busyness of my workday seeing patients! I’m so glad to know more details so I will know more specifically how to pray for you. Regarding the disorganization and chaos, is there any way to make inroads in terms of a systems wide approach? You are so good at that kind of thing, seeing the big picture in the midst of a myriad of details…. Carolyn, thanks so much for writing your blog and keeping us all in the loop. You are a very special person. xoxox Bonnie